ichieli M

Dendritic cell recovery after autologous stem cell transplantation

There is persistent immunosuppression not only in allogeneic but also in autologous stem cell transplantation because humoral and cellular immunity may take a year or more to return to normal, with increased risk of infectious complications. This immune defect may also involve antigen presentation, in particular dendritic cell (DC) function. We evaluated DC subset reconstitution in 58 patients who underwent bone marrow (BM) or peripheral blood (PB) autologous haematopoietic stem cell transplantation (HSCT). In all patients DC type 1 (DC1) and DC type 2 (DC2) were already significantly lower than in normal individuals before conditioning therapy (DC1/μl 3.1 ± 1.0, DC2/μl 3.0 ± 1.1). On day 0 and day +7 the mean DC1 and DC2 numbers were very low in both groups. Patients who received unmanipulated marrow or peripheral blood stem cells reached pre-conditioning levels of DC1 and DC2 cells on day +20. In patients receiving selected CD34 cells, DC increased slowly and pre-transplant counts were observed only on day +60. Nearly ‘normal’ levels of DC1 and DC2 could be observed in the first group from day +180, and were maintained thereafter; in CD34+ selected patients DC1 and DC2 counts remained lower than normal. Our data emphasise that circulating antigen presenting cells (APC) recover quickly. It remains to be determined if DC frequency in PB reflects their tissue function. The relatively low incidence of infections in patients undergoing autologous transplantation, despite defective lymphocyte reconstitution, could be related to functionally efficient DC.

Fludarabine, Arabinosyl Cytosine and Idarubicin (FLAI) for Remission Induction in Poor-Risk Acute Myeloid Leukemia

Progress in treatment of acute myeloid leukemia (AML) is slow and treatment intensification alone has limited effects, particularly in poor-risk cases. Poor-risk cases, that are identified mainly by prior history, leukemic cell mass and cytogenetic abnormalities, share multiple mechanisms of drug resistance that are responsible for treatment failure. Since Pgp-mediated resistance to anthracycline can be reduced with Idarubicin (IDA) and resistance to arabinosyl cytosine (AC) can be reduced with Fludarabine (FLUDA), we tested a combination of high dose AC (2000mg/sqm, 5 doses), FLUDA (30 mg/sqm, 5 doses) and IDA (12mg/sqm, 3 doses) for remission induction and consolidation in 45 consecutive cases of poor-risk AML. The complete remission (CR) rate was 71 % after the first course and 82% overall, with a projected 2-year survival and relapse-free survival of 44% and 50% respectively. Non-hematologic toxicity was very mild, that is very important in elderly patients, but hemopoietic toxicity was substantial, with a time to hematologic recovery of 3 to 4 weeks and two cases of death in CR. Peripheral blood stem cells (PBSC) could be mobilized and collected successfully only in 11 cases. This three-drug combination is effective and has a limited non-hematologic toxicity, but FLUDA may increase the difficulty of obtaining PBSC early after remission induction.

Evaluation of the clinical relevance of the anionic glutathione-s-transferase (GST pi) and multidrug resistance (mdr-1) gene coexpression in leukemias and lymphomas.

By using RNA slot-blot technique, the frequency and the degree of GST pi and mdr-1 gene coexpression were investigated in 23 AML patients, 9 ALL, 9 CLL and 11 cases of NHL in an attempt to study their clinical and prognostic relevance. GST pi and mdr-1 levels were expressed as arbitrary units (U) with respect to the negative controls (U = 0), MCF7 and HL60 sensitive cell lines, and the positive controls (U = 10), MCF7/DOXO and HL60/DNR resistant cell lines. The concomitant GST pi/mdr-1 gene overexpression showed a negative prognostic value in the set of newly diagnosed AML pts (10 cases), furthermore higher GST pi and mdr-1 mRNA levels were averagely detected in the relapsed/resistant ALL pts (4 cases), and in CLL (7 cases) and NHL (8 cases) heavily pretreated patients who were unresponsive to chemotherapy and with a disease progression. These preliminary data show that two different mechanisms of drug resistance can be coexpressed at the same time in those leukemias and lymphomas with a clinically unfavourable course.

Efficacy and tolerability of repeated cycles of a once-weekly regimen of bortezomib in lupus

SIR, Fröhlich et al. [1] described in 2011 the first case of the successful use of twice-weekly bortezomib, a proteasome inhibitor (1.5 mg on days 1, 4, 8 and 11 of each 28day cycle, for three cycles), in a patient with SLE and concomitant multiple myeloma (MM), supporting the preliminary evidence of the efficacy of bortezomib in mouse models of lupus [2, 3]. The susceptibility of cells to bortezomib is related to the extent of protein production in general, and to the extent of Ig production in myeloma B cells in particular [4]. In SLE, long-lived plasma cells, which are the major source of autoantibody-producing B cells, are generally resistant to immunosuppressive therapies, including the most recent biologic B cell targeting agents. Persistence of the disease or flares may be imputable to survival of such long-lived plasma cells [5], and the efficacy of bortezomib in SLE may be linked to the killing of long-lived and short-lived plasma cells. However, no other reports of bortezomib therapy in SLE have been subsequently published, and a trial in SLE with a standard dose-intensity regimen with bortezomib has been withdrawn (Velcade for proliferative lupus nephritis; www.ClinicalTrials.gov). Polyneuropathy, thrombocytopenia and gastrointestinal complaints are frequent side effects that lead to early discontinuation of bortezomib in more than one-third of MM patients. This raises major questions on the feasibility of bortezomib in younger patients with SLE as well as its potential efficacy [6, 7]. One recently proposed option to minimize the toxicity of bortezomib in MM is a longer interval for the administration of the drug—i.e. weekly or longer [8, 9]. Based on these new therapeutic schedules of administration of bortezomib, it is possible to treat MM in patients who are not suitable for a full dose-intensity regimen [8, 9], and the same schedules might be useful in SLE. We report the case of a 70-year-old woman who suffered from SLE and anti-phospholipid syndrome (APS), with both diseases fulfilling the ACR classification criteria, characterized by photosensitivity, serositis, lymphopenia, venous thrombosis and multiple ischaemic lesions on cerebral MRI, positivity of anti-Sm and anti-RNP autoantibodies, high-titre aCL IgG, and lupus anticoagulant. Renal involvement was absent. The patient also suffered from autoimmune thyroiditis. Treatment with AZA and low doses of glucocorticoids had been used in the past, while other immunosuppressants had been avoided mainly because of recurrent herpetic keratitis (requiring continuous prophylaxis with antiviral drugs) and the low level of disease activity (ECLAM score, 2; SLEDAI score, 2). Platelet anti-aggregants were used for APS. In 2009 MM (IgA ) was diagnosed, in stage I according to Salmon and Durie (bone marrow infiltration 15%), evolving from a monoclonal gammopathy of undetermined significance (MGUS) (IgA MGUS) known since 2001. Due to the increasing IgA levels (from 1630 to 2600 mg/dl in 3 months), the patient was treated with once-weekly bortezomib infusions [1.3 mg/m i.v. on days 1, 8, 15 and 22 (for four cycles)] and dexamethasone 40 mg, obtaining a long-term partial response of the MM and negativization of SLE-related autoantibodies (ANA and anti-Sm). Both the ECLAM and SLEDAI scores decreased to zero. At the beginning of 2012, progression of the MM was revealed by a substantial increase in IgA and serum b2-microglobulin, while SLE was in remission and autoantibodies were negative. Bortezomib was repurposed at the same regimen of 1.3 mg/m/week for 4 weeks (four cycles) plus dexamethasone. From the fifth cycle, CYC 50 mg every other day for 2 months was added. The treatment was interrupted after the sixth cycle, since a new partial remission of the MM was obtained, with SLE remaining in remission. The overall tolerability of the two cycles of treatment was good, and only a grade 1 peripheral neuropathy occurred, with no reactivation of herpetic keratitis. At the last available follow-up (36 months after the first bortezomib cycle), SLE persisted in remission and the prednisolone dose was 5 mg/day. The case reported herein highlights the possible usefulness of the once-weekly regimen of bortezomib therapy in SLE. This regimen has already been introduced in MM trials, leading to a decrease in haematological, gastrointestinal and neurological side effects, accompanied by a similar efficacy [8, 10]. Importantly, bortezomib was well tolerated in association with steroids in the present case, and very low doses of oral CYC were subsequently allowed. The evaluation of short-lived and long-lived plasma cells was not performed during bortezomib treatment in this patient. However, the autoantibodies soon became negative after the first cycle of treatment, consistent with a biological activity of the treatment on plasma cells and with the clinical efficacy observed in SLE. On the other hand, since SLE was only mildly active in our patient, the efficacy of the reported regimen of bortezomib remains to be evaluated in more active SLE, which could represent a more common therapeutic target. The possible use of bortezomib in SLE is described herein when using delayed infusions of the drug. Since bortezomib might represent an important therapeutic option in selected patients with SLE, further investigation would be worthwhile.

BU/melphalan and auto-SCT in AML patients in first CR: a ‘Gruppo Italiano Trapianto di Midollo Osseo (GITMO)’ retrospective study

AML patients (total 129; median age =50 years; range 16–72) in first CR received BU and melphalan (BU/Mel) as conditioning regimen before auto-SCT. In all, 82 patients (63.6%) received PBSCs and 47 patients (36.4%) received BM cells. The distribution of cytogenetic categories was conventionally defined as favorable (15.5%), intermediate (60.1%) and unfavorable (24.3%). With a median follow-up of 31 months, the 8-year projected OS and disease-free survival (DFS) was 62 and 56% for the whole population, respectively. The relapse rate was 46% and the non-relapse mortality was 4.65%. Although PBSC transplantation led to a faster hematological recovery than BM transplantation, in univariate analysis the stem cell source, cytogenetics and different BU formulations did not significantly affect OS and DFS, whereas age and the number of post-remission chemotherapy cycles did have a significant effect on the clinical outcome. Multivariate analysis identified age <55 years as the only important independent predictor for OS and DFS. Our data suggest that BU/Mel, being associated with a low toxicity profile (mainly mucositis) and mortality, is an effective conditioning regimen even for high-risk AML patients in first CR undergoing auto-SCT.

Autologous bone marrow transplantation in non-Hodgkin's lymphoma patients: effect of a brief course of G-CSF on harvest and recovery.

This study compares harvest and hematological recovery data of 100 lymphoma patients who underwent BM harvest either after a short course of G-CSF (16u2009μg/kg for 3 days) (nu2009=u200957) or in steady-state conditions (nu2009=u200943). G-CSF allowed the attainment of a significantly higher median number of total nucleated cellsu2009×u2009108/kg (4.4, range 1.4–17, vs 2.1, range 0.6–4.2; Pu2009<u20090.0001), mononuclear cellsu2009×u2009108/kg (0.55, range 0.20–1.4, vs 0.41, range 0.15–0.76, Pu2009<u20090.0001) and cfu-gm/ml (310, range 10–5500, vs 80, range 10–3800, Pu2009=u20090.008), with lower volumes of blood collected (17.5u2009ml/kg, range 8–31 vs 21.0, range 15–30, Pu2009=u20090.0001). Hematological recovery was faster in patients who received pre-treated BM (median time to PMN >0.5u2009×u2009109/l and to platelets >20u2009×u2009109/l was 12, range 10–14, and 13, range 10–18, days, respectively) than in those autotransplanted with steady-state BM (median time to PMN >0.5u2009×u2009109/l and to platelets >20u2009×u2009109/l 13, range 10–18 and 14, range 10–20 days, respectively, Pu2009=u20090.004 and Pu2009=u20090.01). Transfusional requirement was significantly different and patients of the G-CSF group needed shorter hospitalization (17 days, range 12–24, vs 20 days, range 14–32; Pu2009=u20090.02). These data suggest that treating patients with G-CSF before BM harvest improves the quality of the harvest and accelerates engraftment and hematological recovery.